Urban mental health and psychosocial support in Egypt

In complicated urban contexts, organisations must redesign established models of MHPSS intervention in order to ensure that services are accessible to the most vulnerable and are context-specific. It is not possible merely to move camp-designed interventions to the urban context.

Refugees in Egypt, like those across the world, struggle to find an adequate quality of life. Asylum seekers come to Egypt hoping that their stay will be temporary, they will be cared for by UNHCR and they will be resettled to a Western country. This hope quickly diminishes. UNHCR and its partners have limited resources and financially can assist only a small percentage of the vulnerable. Meanwhile, fewer than 5% are resettled annually.

The Psycho-Social Services and Training Institute in Cairo (PSTIC) concentrates on helping people find what they can do to become self-reliant rather than bemoaning the system’s lack of resources. PSTIC targets the most vulnerable of those registered with UNHCR including people who are homeless, hungry, sick and unable to be self-reliant; who struggle due to gender-based, community or family violence; who feel overwhelmed by distress, despair and traumatic experiences; who are marginalised or rejected; and who are chronically ill, disabled or with poor mental health.[1]

During their attempts to assist people to solve problems, PSTIC workers help people manage their feelings of entitlement, dependency, disappointment and anger. PSTIC also concentrates on building families’ capacities for self-help; for example, activities are not designed for children alone but rather to build the capacities of families to assist their own children. When there is no family, or the family is unable to help, PSTIC facilitates communities to become responsible for assisting their vulnerable members.

‘Of the community’

Migrant groups in urban contexts often establish national, tribal and religious communities which have physical centres with regular activities, designated members and elected leadership. The PSTIC Teams are ‘of the community’ and can therefore access these communities. Over 160 of PSTIC’s 180 workers are refugees, asylum seekers or migrants from the nationalities most represented in Egypt: Eritrea, Ethiopia, Somalia, South Sudan, Sudan, Iraq, Syria and Yemen. The workers live in their communities and have first-hand awareness of issues and can provide practical interventions in accordance with culture and context in the languages spoken by their communities.

PSTIC does not replace but rather supplements community leaders. It respects the authority of elected leaders and their traditional influence to resolve problems. PSTIC workers, however, are trained to manage a range of issues that are often not within the expertise of community leaders. With PSTIC workers and community leaders working together over time, community leaders have gained greater understanding and new skills to manage mental illness, suicide risk, substance abuse, child protection needs and the protection of women. They identify people in need and can assist responsibly or they refer cases to PSTIC and other service providers.

PSTIC’s workers are selected in cooperation with their urban communities. Many were community leaders before joining PSTIC. They are a paid team of refugees, trained to offer MHPSS support; they have no offices and provide assistance through home and community visits using a ‘desk in a backpack’ approach.

These workers have little prior training or experience in MHPSS. They were teachers, IT workers, lawyers, agriculturalists, at-home mothers or house cleaners before being hired. They are chosen because of their personalities, motivation, compassion and experience in helping in their communities rather than because of their levels of education. They are taught essential knowledge and practical psychosocial support skills and helped to broaden their attitudes to enable them to help anyone in need without discrimination. They learn professional ethics and the application of basic human rights in order to equitably assist women and children and people with special needs including those with differences in gender or sexual identity.

As refugees, PSTIC workers have had few opportunities in Egypt, so most feel grateful for work that not only provides an income but helps those in need and also gains them the respect of their communities. However, working at PSTIC can be challenging and emotionally draining. Though beneficial, the ‘of the community’ model does create challenges. PSTIC workers must manage sometimes competing community allegiances versus professional ethics. Workers have individual supervision, weekly team meetings and monthly supportive group sessions to share personal and professional challenges. To ensure full transparency, communities also have opportunities to complain about workers and services through helplines and community meetings.

People’s problems are not confined to usual office working hours, and services must be delivered when and where they are needed. This requires the cooperation of workers and their agreement that 24-7 response is essential. With this model, serious attention to staff care is critical. Importantly, workers must feel safe if they have to respond at night. At PSTIC, no worker responds to an emergency alone and they are given emotional support during and after, with praise for a job well done.

COVID-19 temporarily restricted the fieldwork of PSTIC workers and forced them to provide assistance by telephone and only respond in person to life-threatening emergencies. During the height of the pandemic, PSTIC workers often called people daily, knowing how stressed they were due to losing control over their ability to be self-reliant, uncertainty of the situation, confinement to home, and loss of work and income. Slowly, PSTIC workers have been able to return to the field, taking precautions to minimise infection. Workers wear masks and arrange with those whom they visit to wear masks during their home sessions. For overcrowded households, workers now offer some support in refugee community-based centres.

‘One-stop shop’ approach

To meet the needs of the most vulnerable, PSTIC has learned that it must have interventions at all four layers of the IASC MHPSS pyramid of interventions for emergency settings (see below).[2] PSTIC therefore carefully combines the provision of layers of intervention into individualised plans of action and complements services offered by the government and other entities.

Social support through family, friends or community is essential as a cornerstone of each individualised plan of action. PSTIC’s workers assist people to find a safe system of support and build the capacities and responsibility of this support system. No one asking PSTIC’s help is refused. PSTIC workers assist and refer and when no service is possible, they listen and offer kindness. Recognising that the most vulnerable may not know how to ask for help, workers will take the initiative to call or knock on someone’s door to offer assistance when they are told there is a problem.

For example, a person attempts suicide. Her roommate calls a PSTIC refugee worker who goes to her home and does an immediate assessment. The woman cries and says she does not want to die but feels lonely and frightened. Due to COVID-19, she lost her job and cannot pay her rent. The PSTIC worker sits with her and her roommate and makes a plan for support and protection. A psychiatrist is on the phone consulting with the PSTIC worker and does a telephone assessment with the client. All agree she can be safe at home with the protection of her roommate and they set up a psychiatric clinic appointment for the next day. PSTIC helps alleviate her immediate distress by arranging temporary food vouchers and payment of her rent until she can find a new job.

Interventions at Layer 1 of the pyramid offer practical assistance to reduce distress. PSTIC’s

24-7 helplines are widely advertised. Helpline staff offer information and referral, and arrange for workers to go immediately to someone’s home when needed.

Inaccurate information is often a cause of distress. The Information Sharing Team shares accurate information in informal community settings. To manage the distress caused by

COVID-19, PSTIC increased its information sharing through a MHPSS Facebook page sharing information in six languages.[3] A Housing Initiative Team provides emergency response to secure safe affordable housing, mediate conflicts with landlords and teach financial planning. Additionally, a Health Advocacy Medical Team assists refugees to access emergency medical care with nurses also providing home-based health care for people who are confined to bed.

Interventions at the second, third and fourth layers of the MHPSS pyramid include a Psychosocial Team of trained refugees who assess needs, prepare individualised case plans, and provide counselling and conflict mediation, community integration, advocacy, accompaniment and referral. The team offers intensive management for child and family protection, mediators for gang violence, school-based activities for boys to promote non-violent activities and specialised play groups for children with special needs and their families. This team works to minimise stigma in the community, facilitate community integration and – through home visits – promote compliance with mental health treatment. A Counselling Team of multilingual refugee counsellors offers short-term goal-directed individual, couple and family counselling, while the Mental Health Team of Egyptian psychiatrists acts alongside refugee psychosocial workers to provide psychotherapy and psychiatric treatment in PSTIC clinics for people with serious mental illness.

Urban environments pose many challenges for the provision of mental health and psychosocial support to displaced populations. In such contexts, MHPSS interventions need to be accessible to the most vulnerable and designed for each unique context. The PSTIC 24-7 community-based urban model has gained international recognition and its international training institute, Urban Life,[4] has welcomed trainees from 15 countries to join field-based training. The practices developed by PSTIC to meet urban challenges in Cairo can offer lessons to those working in urban centres elsewhere.

 

Nancy Baron drnancybaron@pstic-egypt.org

Director, Psycho-Social Services and Training Institute in Cairo (PSTIC) (a programme of Terre des hommes)

 

[1] PSTIC assists about 2,000 cases (8,000 individuals) monthly. http://pstic-egypt.org

[2] IASC (2007) IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings , pp11–13
https://interagencystandingcommittee.org/system/files/2020-11/IASC%20Guidelines%20on%20Mental%20Health%20and%20Psychosocial%20Support%20in%20Emergency%20Settings%20%28English%29.pdf

[3] www.facebook.com/RefugeesTogether/

[4] www.urbanlifemhpss.com

 

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